Transcript
Chapter 12: Inflammation and Wound HealingTest Bank MULTIPL CH!IC 1. The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. ssess the wound every ! hours. N #$ The incisional redness and warmth are indicators of the normal initial %inflammatory& stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider' assessment every ! hours' and obtaining wound cultures are not indicated because the healing is progressing normally. D()#*ognitive +evel# pply %application&,-)#1/10TO#Nursing rocess# ssessment2 *#N*+-3# hysiological (ntegrity!. patient with an open leg wound has a white blood cell %W$*& count of 14' 56678+ and a band count of 119. What action should the nurse ta:e first ? a. Obtain wound cultures. b. tart antibiotic therapy. c. ,edress the wound with wet/to/dry dressings. d. *ontinue to monitor the wound for purulent drainage. N # The increase in W$* count with the increased bands %shift to the left& indicates that the patient probably has a bacterial infection' and the nurse should obtain wound cultures. ntibiotic therapy and7or dressing changes may be started' but cultures should be done first. The nurse will continue to monitor the wound' but additional actions are needed as well. D()#*ognitive +evel# pply %application&,-)#14O$;# pecial <uestions# rioriti=ationTO#Nursing rocess# lanning2 *#N*+-3# hysiological (ntegrity4. patient with a systemic bacterial infection feels cold and has a sha:ing chill. Which assessment finding will the nurse e>pect ne t ? a. :in flushing b. 2uscle cramps c. ,ising body temperature d. Decreasing blood pressure N #* The patient’s complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. $ecause associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur' s:in flushing and hypotension are not e>pected. 2uscle cramps are not e>pected with chills and shivering or with a rising temperature. D()#*ognitive +evel# pply %application&,-)#1/15TO#Nursing rocess# ssessment2 *#N*+-3# hysiological (ntegrity. young adult patient who is receiving antibiotics for an infected leg wound has a temperatureof 161.0@ ) %40.@ *&. Which action by the nurse is most appropriate? a. pply a cooling blan:et. b. Notify the health care provider. c. Aive the prescribed ,N aspirin %scriptin& B56 mg. d. *hec: the patient’s oral temperature again in hours. N #D 2ild to moderate temperature elevations %less than 164@ )& do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. ntipyretics are not indicated unless the patient is complaining of fever/related symptoms. There is no need to notify the patient’s health care provider or to use a cooling blan:et for a moderate temperature elevation. D()#*ognitive +evel# pply %application&,-)#1BTO#Nursing rocess# (mplementation2 *#N*+-3# hysiological (ntegrity5. patient’s × 4/cm leg wound has a 6. cm blac: area in the center of the wound surrounded by yellow/green semiliCuid material. Which dressing should the nurse apply to the wound? a. Dry gau=e dressing %erli>& b. Nonadherent dressing %3eroform& c. Eydrocolloid dressing %DuoDerm& d. Transparent film dressing %Tegaderm& N #* The wound reCuires debridement of the necrotic areas and absorption of the yellow/green slough. hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or appro>imated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound. D()#*ognitive +evel# pply %application&,-)#10! F 1GTO#Nursing rocess# (mplementation2 *#N*+-3# hysiological (ntegrityB. patient has an open surgical wound on the abdomen that contains deep pin: granulation tissue. Eow would the nurse document this wound? a. ,ed wound b. Hellow wound c. )ull/thic:ness wound d. tage ((( pressure ulcer N # The description is consistent with a red wound. stage ((( pressure ulcer would e>pose subcutaneous fat. yellow wound would have creamy colored e>udate. full/thic:ness wound involves subcutaneous tissue' which is not indicated in the wound description. D()#*ognitive +evel# Inderstand %comprehension&,-)#1GTO#Nursing rocess# ssessment2 *#N*+-3# hysiological (ntegrity. patient with rheumatoid arthritis has been ta:ing corticosteroids for 11 months. Which nursing action is most li:ely to detect early signs of infection in this patient? a. 2onitor white blood cell count. b. *hec: the s:in for areas of redness. c. *hec: the temperature every ! hours. d. s: about fatigue or feelings of malaise. N #D *ommon clinical manifestations of inflammation and infection are freCuently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be JKust not feeling well.L D()#*ognitive +evel# pply %application&,-)#1BTO#Nursing rocess# ssessment2 *#N*+-3# hysiological (ntegrity0. The nurse should plan to use a wet/to/dry dressing for which patient? a. patient who has a pressure ulcer with pin: granulation tissue b. patient who has a surgical incision with pin:' appro>imated edges c. patient who has a full/thic:ness burn filled with dry' blac: material d. patient who has a wound with purulent drainage and dry brown areas N #D Wet/to/dry dressings are used when there is minimal eschar to be removed. full/thic:ness wound filled with eschar will reCuire interventions such as surgical debridement to remove thenecrotic tissue. Wet/to/dry dressings are not needed on appro>imated surgical incisions. Wet/to/dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue. D()#*ognitive +evel# pply %application&,-)#10 F 104TO#Nursing rocess# lanning2 *#N*+-3# hysiological (ntegrityG. patient from a long/term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. Eow should the nurse classify this pressure ulcer? a. tage ( b. tage (( c. tage ((( d. tage (M N #* stage ((( pressure ulcer has full/thic:ness s:in damage and e>tends into the subcutaneous tissue. stage ( pressure ulcer has intact s:in with some observable damage such as redness or a boggy feel. tage (( pressure ulcers have partial/thic:ness s:in loss. tage (M pressure ulcers have full/thic:ness damage with tissue necrosis' e>tensive damage' or damage to bone' muscle' or supporting tissues. D()#*ognitive +evel# Inderstand %comprehension&,-)#105TO#Nursing rocess# ssessment2 *#N*+-3# hysiological (ntegrity16. young male patient who is a paraplegic has a stage (( sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage' what instructions are most important for the nurse to teach the mother? a. *hange the patient’s bedding freCuently. b. Ise a hydrocolloid dressing over the ulcer. c. ,ecord the si=e and appearance of the ulcer wee:ly. d. *hange the patient’s position at least every ! hours. N #D The most important intervention is to avoid prolonged pressure on bony prominences by freCuent repositioning. The other interventions may also be included in family teaching' but the most important instruction is to change the patient’s position at least every ! hours. D()#*ognitive +evel# pply %application&,-)#10TO#Nursing rocess# (mplementation2 *#N*+-3# hysiological (ntegrity11. The nurse will perform which action when doing a wet/to/dry dressing change on a patient’s stage ((( sacral pressure ulcer? a. oa: the old dressings with sterile saline 46 minutes before removing them. b. our sterile saline onto the new dry dressings after the wound has been pac:ed. c. pply antimicrobial ointment before repac:ing the wound with moist dressings. d. dminister the ordered ,N hydrocodone %+ortab& 46 minutes before the dressing change. N #D 2echanical debridement with wet/to/dry dressings is painful' and patients should receive painmedications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound. oa:ing the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. pplication of antimicrobial ointments is not indicated for a wet/to/dry dressing. D()#*ognitive +evel# pply %application&,-)#104TO#Nursing rocess# (mplementation2 *#N*+-3# hysiological (ntegrity1!. new nurse performs a dressing change on a stage (( left heel pressure ulcer. Which action bythe new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing %DuoDerm& to cover the ulcer. b. The new nurse inserts a sterile cotton/tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 46/m+ syringe. d. The new nurse cleans the ulcer with a sterile dressing soa:ed in half/strength pero>ide. N #D ressure ulcers should not be cleaned with solutions that are cytoto>ic' such as hydrogen pero>ide. The other actions by the new nurse are appropriate. D()#*ognitive +evel# pply %application&,-)#10TO#Nursing rocess# -valuation2 *#N*+-3# afe and -ffective *are -nvironment
